Multiple Choice Questions

Upper Limb Pathology

Test your knowledge , learn more and get ready for your orthopaedic exam

 51. What muscles will lose power due to the with stab injury to the median nerve in proximal forearm?

A) Flexor pollicis longus and abductor pollicis longus
B) First two lumbricals and abductor pollicis brevis
C) Flexor digitorum profundus and flexor carpi ulnaris
D) Flexor digitorum superficialis and first two palmar interossei
E) First two dorsal and palmar interossei

Correct Answer :B

In the cubital fossa, the median nerve supplies pronator teres, palmaris longus, FCR, FDS. Occasionally PT is supplied above the elbow. In the forearm it gives off the anterior interosseous nerve which supplies FPL, PQ and usually the radial half of FDP (index and middle). In the hand the median nerve gives off the recurrent motor branch supplying APB, FPB and opponens pollicis muscles. The palmar digital branches supply the two radial lumbricals.

Author : Firas Arnaout

 50. With regards to Wartenberg’s Syndrome, which one of the following statements is true?

A) Typically associated with weakness of wrist dorsiflexion
B) Paraesthesiae along the dorso-radial side of the hand
C) Pain along the ulnar side of forearm
D) Aggravated by forearm supination
E) Surgery is usually required

Correct Answer :B

Wartenberg’s syndrome is caused by compression of the superficial sensory branch of the radial nerve between the tendons of brachioradialis and extensor carpi radialis longus with forearm pronation. Symptoms include pain, numbness and paraesthesia over the dorsoradial aspect of the hand. Provocative tests include forceful forearm pronation for 60 seconds and a Tinel sign over the nerve.

Author : Firas Arnaout

 49. Care should be taken to avoid the dorsal sensory branch of the ulnar nerve while performing ulnar shortening osteotomy. Please select the direction of this nerve while crossing the wrist joint from the following options:

A) From volar to dorsal just distal to the ulnar styloid, at an angle of 45° to the long axis of the forearm
B) From dorsal to volar just proximal to the ulnar styloid, at an angle of 45° to the long axis of the forearm
C) From volar to dorsal just distal to the radial styloid, at an angle of 45° to the long axis of the forearm
D) From dorsal to volar just distal to the ulnar styloid, at an angle of 45° to the long axis of the forearm
E) From volar to dorsal just proximal to the ulnar styloid, at an angle of 45° to the long axis of the forearm

Correct Answer :A

The sensory branch originates on average 5 cm proximal to the ulnar styloid process and 2 cm radial to the subcutaneous border of the ulna. The nerve crossed the subcutaneous border of the ulnar from volar to dorsal on average 0.2 + 1.1 cm proximal to the ulnar styloid process

Author : Firas Arnaout

 48. What shoulder examination is a test for impingement?

A) Crank test
B) Hawkins’ test
C) O’Brien’s test
D) Rubber band sign
E) Speed’s test

Correct Answer : B

Hawkins’ test is passive forward flexion and internal rotation. If there is pain at 90 degrees then there is possible acromion impingement. If pain at 120 degrees then there is possible acromioclavicular joint (ACJ) joint impingement.

Speed’s test is used to examine the proximal tendon of the long head of the biceps. Forward flex the shoulder (60 degrees) against resistance while maintaining the elbow in extension and the forearm in supination – tenderness in the bicipital groove indicates bicipital tendinitis.

O’Brien’s test is the shoulder held in 90 degrees of forward flexion, 30 to 45 degrees of horizontal adduction and maximal internal rotation. Grab the patient’s wrist and resist the patient’s attempt to horizontally adduct and forward flex the shoulder.

Rubber band sign is resisted maximal external rotation. Pain is experienced in infraspinatus lesion.

Crank test – full abduction, humeral loading and rotation. Pain is experienced in SLAP lesion.

Author : Firas Arnaout

 

47. With regards to the ‘Painful Arc Syndrome’, which of the following statements is true:

A) Tenderness is generalised
B) Typically there is severe pain on intiating abduction
C) The cause is a tear of the supraspinatus tendon
D) If untreated, a ‘frozen shoulder’ often results
E) Calcification in the region of the Supraspinatus tendon is not seen on X-ray radiographs

Correct Answer : D

If the pt is inhibited in the movement of the shoulder due to pain then the capsule contracts and a frozen shoulder ensues. Other statements are False b/c: Tenderness is usually localised to rotator cuff muscles. Pain is typically on adduction. Tear of Supraspinatus is NOT seen in painful arc syndrome (it rather involves inflammation of Supra Tendon) , but in a rotator cuff tear (different condition). Calcification in the region of Supraspinatus may be seen on X ray since the Syndrome is caused by the inflammation of the same tendon.

Author : Liam Borg

 

46. Which is true of the shoulder joint?

A) Supraspinatus is active in abduction
B)The nerve to serratus anterior is derived from the lower roots of the brachial plexus
C) The rotator cuff muscles are attached to the capsule which is deficient anteriorly
D) The subacromial bursa communicates with the shoulder joint
E) She subscapular nerve arises from the lateral cord of the brachial plexus

Correct Answer: A

During abduction the supraspinatus muscle fixes the humeral head against the glenoid cavity while deltoid contracts.
The rotator cuff muscles (supraspinatus, infraspinatus, teres minor and subscapularis) serve to hold the head of the humerus in the shallow glenoid cavity during movement. They are attached to the capsule of the joint.
The rotator cuff is deficient inferiorly which results in an area of potential weakness. During abduction the supraspinatus muscle fixes the humeral head against the glenoid cavity while deltoid contracts.
The subacromial bursa does not connect with the shoulder joint.
The nerve to serratus anterior, that is, the long thoracic nerve has nerve roots C5-C7.
Both the upper and lower subscapular nerves are derived from the posterior cord of the brachial plexus.

Author: Firas Arnaout

 

45. Which one of the following is NOT a recognised complication of Colles’ Fracture

A) Loss of Palmar Flexion
B) Sudek’s Atrophy
C) Median Nerve Compression
D) Loss of full Supination
E) Avascular necrosis (AVN) of the Lunate bone

Correct Answer : E

 AVN of Lunate is NOT a complication of Colles’ fracture, and occurs spontaneously with unknown aetiology. Other Statements are correct. Palmar flexion might be initially lost prior to reduction due to the dorsal displacement of the wrist joint and hence limited arc of motion. Sudek’s atrophy is a rare but a recognised complication of Colles fracture (presenting with a pain, stiffness + swelling, sweaty, cold wrist. Median nerve Compression might occur due to a haematoma compressing it at the carpal tunnel. Loss of Supination is a potential complication of the distal radial fracture, esp in cases of malunion since the fragment prevents the distal radioulnar joint from supinating fully due to bony fragment.

Author : Liam Borg

 

44. Which one of the following is NOT a recognised cause of Carpal Tunnel Syndrome (CTS):

A) Fractured of Distal Radius
B) Fractured Scaphoid
C) Pregnancy
D) Dislocated Lunate
E) Rheumatoid Arthritis

Correct Answer : B

Other options are known causes of CTS, Distal radius fracture can cause median nerve compression through bleeding into the carpal tunnel; Pregnancy causes fluid retention with subsequent CTS; Lunate bone dislocation anteriorly causes direct compression of median nerve; Synovial hypertrophy in RA causes CTS.

Author : Liam Borg

 

43. Which of the following correctly pairs the anatomical space of the shoulder with its contents?

A) Quadrangular space; radial nerve and profunda brachii artery
B) Quadrangular space; axillary nerve and scapular circumflex artery
C) Quadrangular space; axillary nerve and posterior humeral circumflex artery
D) Triangular space; axillary nerve and posterior humeral circumflex artery
E) Triangular space; radial nerve and profunda brachii artery

Correct Answer : C

The quadrangular (quadrilateral) space of the shoulder contains the axillary nerve and posterior humeral circumflex artery.
The shoulder contains three anatomically importance spaces: the quadrangular (quadrilateral) space, the triangular space, and the triangular interval. 

The quadrangular space contains the axillary nerve and posterior humeral circumflex artery, and is bordered by the long head of the triceps medially, humeral shaft laterally, teres minor superiorly, and teres major inferiorly. 

The triangular space contains the scapular circumflex artery, and is bordered by the long head of the triceps laterally, teres minur superiorly, and teres major inferiorly. Finally, the triangular interval contains the radial nerve and profunda brachii artery, and is bordered by the long head of the triceps medially, lateral head of the triceps or humerus laterally, and teres major superiorly.

 

Author : Firas Arnaout

 

42. 21-year-old infantryman dislocates his shoulder during basic training. He is able to make it through training but continues to experience recurrent dislocations. 

A CT demonstrates anterior glenoid bone loss and your sports colleagues indicate him for a Latarjet procedure. The procedure successfully restores stability to his shoulder, but the patient is referred to your office just over 3 months later because he has persistent difficulty with abduction when the arm is internally rotated. 

You suspect an iatrogenic nerve injury sustained during anterior shoulder exposure and offer him a nerve transfer procedure involving the branch of the radial nerve that innervates the medial head of triceps. 

The nerve that is injured in this patient innervates what muscles?

A) Deltoid, teres minor, and supraspinatus
B) Deltoid, teres minor, and teres major
C) Teres minor and teres major
D) Deltoid and teres major
E) Deltoid and teres minor

Correct Answer : E

This patient sustained an axillary nerve injury during a large anterior exposure to the shoulder. The patient is offered a Leechavengvongs radial to axillary nerve transfer, as this will potentially restore the lost axillary nerve function to the deltoid and teres minor. 

The axillary nerve branches off of the posterior cord (along with the radial nerve) of the brachial plexus, travels just inferior to the subscapularis, then winds posterior and travels through the quadrangular space with the posterior circumflex humeral artery. 

The anterior branch innervates the anterior half of the deltoid, while the posterior branch innervates the posterior portion of the deltoid and the teres minor. 

This posterior branch also supplies the lateral cutaneous nerve of the arm. Axillary nerve injury is an uncommon but potentially debilitating complication of shoulder surgery. 

Physical exam would be significant for partial or complete deltoid paralysis, which would be most evident with tested shoulder abduction while in internal rotation. In internal rotation, the supraspinatus is rotated anteriorly and thereby contributes less to abduction. 

The Leechavengvongs procedure involves the transfer of one branch of the radial nerve (to medial, lateral, or long head of the triceps) to the axillary nerve. The goal is to get as much excursion of the radial nerve as possible and transferring the branch as proximally as possible on the axillary nerve

 

Author : Firas Arnaout

 

41. Which Muscle or Muscles would be most affected by this lesion?

A) Deltoid
B) Teres Minor
C) Supraspinatus  
D) Infraspinatus
E) Subscapularis

Correct Answer: D

Infraspinatus this is a cyst around the suprascapular nerve at scapula notch the branch for Infraspinatus comes after this at splengoid notch whilst Supraspinatus innervated before the scapula notch

Author: David Hughes

 

40. The following are all complications of open vs arthroscopic Lateral epicondylitis release except.

A) Lateral collateral ligament injury
B) Posterior interosseous nerve injury
C) Heterotrophic ossification
D) Flexion-extension limitations
E) Revision Surgery

Correct Answer: B

PIN injury is complication of portal placement in arthroscopic surgery.

Author: David Hughes

 

39. The following are causes of reverse shoulder arthroplasty failure except:

A) Glenoid loosening
B) Scapula notching
C) Supraspinatus dysfunction
D) Axillary nerve dysfunction
E) Poor Bone stock

Correct Answer: C

This is an indication for reverse shoulder arthroplasty.

Author: David Hughes

 

38. The ulnar paradox relates to :

A) Cubital tunnel syndrome is rarely associated with carpal tunnel syndrome
B) A proximal compression of the nerve leads to a worse deformity
C) After cubital tunnel release the deformity gets worse before it gets better
D)Cubital tunnel syndrome is always bilateral
E) Double pinch syndrome has a far worse outcome

Correct Answer: C

After surgery nerves recover proximal to distal so the proximal extrinsic muscles recover first, over powering the intrinsic muscle of the hand causes clawing of the ring and little finger

Author: David Hughes

 

37. What is the most common compression site for the posterior interosseous nerve ?

A) The fibrous bands at the start of the radial tunnel
B) Distal border of the supinator
C) The proximal border of the superficial belly of the supinator (the arcade of Frohse)
D) The tendinous margin of the extensor carpi radialis brevis muscle
E) The leash of Henry

Correct Answer: C

The Arcade of Frohse is a fibrous band that on occasion can cause entrapment of the posterior interosseous nerve leading to the clinical signs and symptoms.

 

 

Author: Bradley Pittam

 

36. When performing elbow arthroscopy, the arthroscopic portal that must be established first is the:

A) Anteromedial portal
B) Anterolateral portal
C) Lateral portal
D) Posterolateral portal
E) Posterior portal

Correct Answer: A

The anteromedial portal is the farthest from the neurovascular structures of the elbow and is the safest to establish. After this portal is established, the joint can be distended, increasing the distance of the other portal sites from the neurovascular structures.

Author: Rajesh Bahadur Lakhey

 

35. Which of the following is the most commonly reported cause of nontraumatic humeral head osteonecrosis?

A) Alcohol abuse
B) Corticosteroid therapy
C) Gaucher’s disease
D) Smoking
E) Hemoglobinopathies

Correct Answer: B

Corticosteroid therapy is the most commonly reported cause of osteonecrosis of the humeral head. 

Other risk factors include alcohol abuse, haemoglobinopathies, Gaucher’s disease, dysbarism, connective tissue disorders, arteritis, vasculitis, hypercoagulability, prior radiation, pregnancy, and pancreatitis.

Author: Rajesh Bahadur Lakhey.

 

34. What is the most common mechanism of anterior dislocation of the sternoclavicular joint?

A) A medially directed force applied to the lateral aspect of the externally rotated shoulder girdle
B) A medially directed force applied to the lateral aspect of the internally rotated shoulder girdle
C) A medially directed force applied to the lateral aspect of the neutrally rotated shoulder girdle
D) An inferiorly directed force applied to the medial aspect of the clavicle
E) A superiorly directed force applied to the medial aspect of the clavicle

Correct Answer: A

The mechanism of sternoclavicular joint injury may be direct or indirect. 

Direct injury involves posteriorly directed forces applied to the medial aspect of the clavicle resulting in proximal clavicular fracture and/or posterior sternoclavicular dislocation. 

More commonly, indirect mechanisms are responsible for sternoclavicular joint injury. Indirect injury occurs when a medial directed force is applied to the lateral aspect of the shoulder. As this force is applied, if the shoulder girdle externally rotates, an anterior sternoclavicular dislocation can occur. If the shoulder internally rotates, then a posterior sternoclavicular joint dislocation may ensue.

Author: Rajesh Bahadur Lakhey.

 

33. This clinical photograph depicts the examination of a 41-year-old man. 

What is the most likely diagnosis based on this finding ?

A) Anterior shoulder instability
B) Posterior shoulder instability
C) Multidirectional shoulder instability
D) Subscapularis tendon tear
E) Biceps tendon rupture

Correct Answer: D

This patient exhibits a positive "belly press" test. As he attempts to press on his abdomen, his wrist goes into flexion and his arm goes into extension because of subscapularis insufficiency.

Author: Rajesh Bahadur Lakhey

 

32. A magnetic resonance image of a patient’s right shoulder is shown. The structure marked by the arrows is innervated by which of the following structures:

A) Musculocutaneous nerve
B) Branch of the posterior cord of the brachial plexus
C) Branch of the lateral cord of the brachial plexus
D) Branch of the medial cord of the brachial plexus
E) Branch of the superior trunk of the brachial plexus

Correct Answer: B

The arrows mark the subscapularis tendon. The subscapularis muscle is innervated by the upper and lower subscapular nerves. 

The upper and lower subscapular nerves are branches from the posterior cord of the brachial plexus.

Author: Rajesh Bahadur Lakhey

 

31. Which of the following structures is the most important dynamic stabilizer of the elbow to valgus stresses during throwing:

A) Anterior oblique component of the ulnar collateral ligament
B) Posterior oblique component of the ulnar collateral ligament
C) Flexor-pronator musculature
D) Brachialis
E) Biceps brachii

Correct Answer: C

The flexor-pronator muscle mass on the medial side of the elbow dynamically resists valgus stresses during throwing.
Compromise or fatigue of this muscle group with activity may be a predecessor to injury to the ligamentous stabilizing
structures.

Author: Rajesh Bahadur Lakhey

 

30. Which of the following factors is related to recurrence after primary anterior shoulder dislocation:

A) Type of sport practiced
B) Treatment with immobilization
C) Treatment with physical therapy
D) Patient gender
E) Patient age

Correct Answer: E

The only known factor that statistically correlates with recurrence of anterior shoulder instability is patient age at the
time of initial dislocation. 

The risk of recurrent dislocations is influenced by the age at the time of initial dislocation. In patients <20 years old the rate of recurrent instability is 72–100%, in those aged between 20-30 years it is 70–82% and in patients >50 years old it is 14–22% (4-11). 

The type of sport practiced, type of nonoperative treatment, and patient gender do not influence recurrence rate.

Reference: Ioannis Polyzois et al . Arch Bone Jt Surg. 2016 Apr; 4(2): 104–108.

Author: Rajesh Bahadur Lakhey

 

29. Which of the following treatment regimens for shoulder internal impingement in overhead athletes has the highest reported rate for return to preinjury competition level ?

A) Subacromial corticosteroid injections
B) Nonsteroidal anti-inflammatory medications
C) Arthroscopic debridement or repair of associated lesions
D) Arthroscopic debridement or repair of associated lesions with thermal capsulorraphy
E) Humeral derotational osteotomy

Correct Answer: D

Internal impingement is an articular sided problem; therefore, use of bursal sided injection has had limited efficacy.
Nonsteroidal anti-inflammatory medications are commonly used in addition to other treatments (e.g. physical therapy),but they are rarely used alone. 

Arthroscopic debridement or repair of associated labral and rotator cuff lesions has resulted in a 67% rate of return to preinjury competition level. When electrothermal capsulorrhaphy was added to the surgical procedure, the rate of return to preinjury competition level increased to 90%. 

Humeral derotational osteotomy yields a 55% rate of return to preinjury competition level with a 30% complication rate.

Author: Rajesh Bahadur Lakhey

 

28. Which of the following is the most commonly reported cause of nontraumatic humeral head osteonecrosis?

A) Alcohol abuse
B) Corticosteroid therapy
C) Gaucher’s disease
D) Smoking
E) Hemoglobinopathies

Correct Answer: B

Corticosteroid therapy is the most commonly reported cause of osteonecrosis of the humeral head. 

Other risk factors include alcohol abuse, haemoglobinopathies, Gaucher’s disease, dysbarism, connective tissue disorders, arteritis, vasculitis, hypercoagulability, prior radiation, pregnancy, and pancreatitis.

Author: Rajesh Bahadur Lakhey.

 

27. A 56-year-old competitive triathelete fell off his bicycle and sustained a traumatic anterior shoulder dislocation. The dislocation was reduced in the emergency room. No associated fractures were noted. 

A magnetic resonance image examination would be judicious in this patient to:

A) Assess the capsuloligamentous integrity of the shoulder
B) Assess for glenoid labrum tears
C) Assess the integrity of the articular cartilage
D) Assess the integrity of the rotator cuff
E) Evaluate the bone for occult fractures

Correct Answer: D

Rotator cuff tears may accompany anterior and inferior glenohumeral dislocations. The frequency of this complication increases with age. In patients older than 40 years incidence exceeds 30%; in patients older than 60 years, the incidence exceeds 80%. 

Shoulder ultrasound, arthrography or MRI is indicated in patients over 40 years of age, with a shoulder dislocation. Prompt repair of these lesions is usually indicated.

Author: Rajesh Bahadur Lakhey

 

26. Which of the following describes the correct relationship between the suprascapular nerve and the suprascapular vessels as they pass through the suprascapular notch:

A) The suprascapular nerve, artery, and vein all pass below the transverse scapular ligament.
B) The suprascapular nerve, artery, and vein all pass superficially to the transverse scapular ligament.
C) The suprascapular nerve passes superficially to the transverse scapular ligament while the artery & vein pass deep to it.
D) The suprascapular nerve and artery pass deep to the transverse scapular ligament while the suprascapular vein passes superficially to it.
E) The suprascapular nerve passes deep to the transverse scapular ligament while the suprascapular artery and vein pass above it.

Correct Answer: E

The suprascapular nerve is a branch of the upper trunk of the brachial plexus at Erb’s point. The suprascapular nerve receives branches primarily from the fifth cervical nerve root. The nerve follows the omohyoid muscle laterally and passes beneath the anterior border of the trapezius muscle to the upper border of the scapula where it joins the suprascapular artery. 

It passes through the suprascapular notch deep to the transverse scapular ligament. The artery and vein pass superficial to the ligament and join the nerve distally in the suprascapular fossa. 

After innervating the supraspinatus muscle, the nerve passes around the lateral free margin of the scapular spine (spinoglenoid notch) to innervate the infraspinatus muscle.

Author: Rajesh Bahadur Lakhey

 

25. Anteroposterior displacement of the acromion on the clavicle is most strongly resisted by which of the following structures:

A) The conoid ligament
B) The acromioclavicular ligaments
C) The osseous articulation of the acromion on the clavicle
D) The acromioclavicular meniscus
E) The trapezoid ligament

Correct Answer: A

During high loads, the coracoclavicular ligaments (conoid and trapezoid ligament) resist vertical and compressive loads across the acromioclavicular joint. The conoid ligament is the strongest ligament resisting downward movement of the scapula relative to the clavicle. 

The acromioclavicular ligaments maintain alignment of the joint in the axial plane.

Author: Rajesh Bahadur Lakhey

 

24. Osteochondritis dissecans of the elbow most commonly occurs at this location:

A) Trochlea
B) Olecranon
C) Capitellum
D) Radial head
E) Coronoid

Correct Answer: C

Osteochondritis dissecans of the elbow is most common in adolescent and pre-adolescent individuals who participate in sports that place an excessive amount of load on the radiocapitellar joint (e.g.baseball pitching, gymnastics). 

Factors involved in the development of this entity include repetitive microtrauma and a tenuous capitellar blood supply. 

Treatment may involve arthroscopic removal of loose bodies.

Author: Rajesh Bahadur Lakhey

 

23. The following structure is most responsible for resisting inferior translation of the glenohumeral joint with the arm at the side:

A) Inferior glenohumeral ligament
B) Middle glenohumeral ligament
C) Coracoacromial ligament
D) Coracohumeral ligament
E) Subscapularis muscle and tendon

Correct Answer: D

The coracohumeral ligament coupled with the superior glenohumeral ligament provides the primary restraint to inferior translation of the glenohumeral joint with the arm at the side. 

The coracohumeral ligament also provides restraint to external rotation with the arm at the side and restraint to posterior translation with the arm adducted, flexed, and internally rotated.

Author: Rajesh Bahadur Lakhey

 

22. The primary restraint to anterior translation of the abducted and externally rotated glenohumeral joint is the:

A) Coracohumeral ligament
B) Superior glenohumeral ligament
C) Middle glenohumeral ligament
D) Inferior glenohumeral ligament
E) Subscapularis muscle

Correct Answer: D

The inferior glenohumeral ligament is the primary restraint to anterior translation of the abducted and externally rotated glenohumeral joint. The Bankart lesion is an avulsion of the inferior glenohumeral ligament and represents the primary pathoanatomy of traumatic anterior shoulder dislocation

Author: Rajesh Bahadur Lakhey

 

21. When comparing open distal clavicle resection with arthroscopic distal clavicle resection for osteolysis of the distal clavicle, arthroscopic techniques:

A) Less reliably resect the appropriate amount ofndistal clavicle
B) Less reliably provide pain relief
C) Have a higher complication rate
D) Require a longer hospital stay
E) Allow quicker return to activity

Correct Answer: E

A study comparing arthroscopic and open techniques of distal clavicular resection in the treatment of osteolysis of the distal clavicle found no difference in the amount of bone resected or amount of pain relief obtained. The arthroscopic group had a shorter hospital stay, less complications, and returned to activity nearly twice as fast as the open group.

Author: Rajesh Bahadur Lakhey

 

20. This slide is a computed tomogram of the dominant shoulder of a 45-year-old male tennis player. 

The most likely diagnosis is:

A) Osteosarcoma
B) Synovial osteochondromatosis
C) Anterior glenoid fracture
D) Synovial cell sarcoma
E) Rotator cuff tear arthropathy

Correct Answer: B

Synovial osteochondromatosis is a rare condition typically affecting middle-aged men. 

The computed tomogram demonstrates the osteocartilaginous nodules. 

Early in the disease, arthroscopic removal of loose bodies and synovectomy usually results in an acceptable outcome. In cases of progressive disease resulting in secondary shoulder arthrosis, shoulder arthroplasty may be required.

Author: Rajesh Bahadur Lakhey

 

19. This is the radiograph of a right hand dominant 15-year-old baseball player who felt a pop when swinging a bat. Recommended treatment should consist of:

A) Immobilization in a shoulder spica cast
B) Immobilization in a sling
C) Open reduction internal fixation with bone graft
D) Open biopsy
E) Observation

Correct Answer: E

First rib fractures in athletes are rare. These fractures are thought to be stress fractures, usually occurring in
pitchers. 

Treatment is observation until the fracture is healed.

Author: Rajesh Bahadur Lakhey

 

18. In a pitcher with an ulnar collateral ligament injury of his dominant elbow, pain is generally most severe during:

A) Wind-up
B) Early cocking
C) Late cocking
D) Follow-through
E) Rest following activity

Correct Answer: C

With ulnar collateral ligament injury, pain is usually exacerbated during the late cocking and the acceleration phases of throwing when the stresses on the ulnar collateral ligament are greatest.

Author: Rajesh Bahadur Lakhey

 

17. What percentage of patients with recurrent anterior shoulder instability has an identifiable abnormality on plain radiography:

A) 10%
B) 25%
C) 75%
D) 85%
E) 95%

Correct Answer: E

Plain radiography can yield osseous abnormalities in up to 95% of shoulders with chronic traumatic anterior shoulder instability, including 75% with humeral head impaction fractures and 85% with a bony glenoid lesion. Bony glenoid lesions include a frank fracture, which can be identified on an anteroposterior view or a glenoid profile view; loss of normal contour of the anterior glenoid rim caused by multiple microimpaction fractures of the anterior glenoid; or a complete bony deficiency of the anterior glenoid caused by resorption of a fracture fragment. 

Osseous abnormalities are most common in shoulders that have a history of prior dislocation and least common in shoulders that are simply painful with no established history of dislocation or subluxation.

Author: Rajesh Bahadur Lakhey

 

16. Which of the following is not considered a mechanism of injury for a superior labrum anterior and posterior (SLAP) tear:

A) Traction injury from carrying, dropping, or lifting a heavy object
B) Compression force from a fall on an outstretched arm
C) Repetitive overhead throwing
D) Forceful biceps contraction with throwing a ball or spiking a volleyball
E) External rotation movement with returning a backhand in tennis

Correct Answer: B

The other mechanisms of injury have been reported in patients with documented SLAP tears. The series by Snyder and colleagues reported that a compressive force from a fall on an outstretched arm was the most common mechanism of injury. However in their study, 21% of the patients with a SLAP lesion reported an insidious onset to their symptoms. Maffet and colleagues reported that two-thirds of patients described a traction injury as the initial traumatic event. In their study, only 8% of patients sustained a fall on their outstretched arm. Most throwing athletes examined by Andrews and colleagues failed to report a distinct traumatic event. 

Thus, while an isolated injury may cause a labral injury, SLAP lesions also may occur as a result of the repetitive microtrauma associated with overhead motions.

Author: Rajesh Bahadur Lakhey

 

15. A magnetic resonance image of a patient’s right shoulder is shown. 

The structure marked by the asterisk is innervated by which of the following structures:

A) Musculocutaneous nerve
B) Branch of the posterior cord of the brachial plexus
C) Branch of the lateral cord of the brachial plexus
D) Branch of the medial cord of the brachial plexus
E) Branch of the superior trunk of the brachial plexus

Correct Answer: E

The asterisk marks the infraspinatus muscle. The infraspinatus muscle is innervated by the suprascapular nerve. The suprascapular nerve is a branch from the superior trunk of the brachial plexus.

Author: Rajesh Bahadur Lakhey

 

14. A magnetic resonance image of a patient’s right shoulder is shown. 

Identify the structure marked by the arrows.

A) Subscapularis tendon
B) Supraspinatus tendon
C) Long head of the biceps tendon
D) Short head of the biceps tendon
E) Coracohumeral ligament

Correct Answer: A

The arrows mark the subscapularis tendon.

Author: Rajesh Bahadur Lakhey

 

13. All of the following muscles act in scapular retraction except:

A) Trapezius
B) Rhomboideus major
C) Rhomboideus minor
D) Levator scapulae
E) Pectoralis minor

Correct Answer: E

The trapezius, rhomboids, and levator scapulae all provide some degree of scapular retraction. 

The pectoralis minor is a scapular protractor.

Author: Rajesh Bahadur Lakhey

 

12. When assessing patient outcomes after rotator cuff repair, which of the following is not related to poor functional outcome:

A) Workman’s compensation
B) Revision rotator cuff repair
C) Male gender
D) Age older than 55 years at the time of repair
E) Age younger than 55 years at the time of repair

Correct Answer: D

A large outcome study of more than 600 rotator cuff repairs demonstrated that workman’s compensation, revision surgery, male gender, and age younger than 55 years at the time of repair are factors contributing to poor functional outcome and decreased workability following rotator cuff repair.

Author: Rajesh Bahadur Lakhey

 

11. To avoid injury associated with repetitive internal impingement, the pitcher’s long humeral axis must be in which
position during the late cocking phase of throwing:

A) 20° extended relative to the plane of the scapula
B) 10° extended relative to the plane of the scapula
C) Parallel to the plane of the scapula
D) 10° flexed relative to the plane of the scapula
E) 20° flexed relative to the plane of the scapula

Correct Answer: C

Hyperangulation during the late cocking phase of throwing can result in impingement of the greater tuberosity on the posterosuperior glenoid rim leading to labral or rotator cuff lesions. Positioning of the humeral axis parallel to the plane of the scapula is recommended to avoid injury associated with internal impingement.

Author: Rajesh Bahadur Lakhey

 

10. Disruption of which of the following ligaments represents the primary lesion in posterolateral rotatory instability of
the elbow:

A) Radial collateral ligament
B) Radial ulnohumeral ligament
C) Annular ligament
D) Accessory radial collateral ligament
E) Ulnohumeral articulation

Correct Answer: B

O’Driscoll and associates demonstrated that the radial ulnohumeral ligament must be disrupted to produce posterolateral rotatory instability of the elbow.

Author: Rajesh Bahadur Lakhey.

 

9. A magnetic resonance image (MRI) of the dominant elbow of a 19-year-old  cricket player is presented . He has been unable to play for the past 6 weeks secondary to pain. 

The recommended treatment includes:

A) Physical therapy for triceps strengthening 
B) Physical therapy for pronator strengthening 
C) Ulnar nerve transpostion 
D) Radial collateral ligament reconstruction 
E) Ulnar collateral ligament reconstruction 

Correct Answer: E

The MRI shows a disruption of the humeral attachment of the ulnar collateral ligament. The ulnar collateral ligament of the elbow is the most frequently observed ligamentous elbow injury in cricket players. 

Recommended treatment in the throwing athlete is reconstruction of the ulnar collateral ligament with an autogenous palmaris longus graft

Author: Fouad Chaudhry

 

8. A “stinger” (transient weakness of the upper extremity commonly seen after a blow to the head and shoulder in contact sports) most commonly affects the:

A) Spinal cord 
B) C-5/C-6 nerve roots 
C) C-7/C-8 nerve roots 
D) Axillary nerve 
E) Musculocutaneous nerve 

Correct Answer: B

"Stingers" are common in contact sports. They generally result from a transient stretch to the C-5/C-6 nerve roots resulting in temporary loss of strength of the biceps, deltoid, and spinatus muscles.

It is generally safe to allow the athlete to return to participation, provided the cervical spine examination is normal and any neurological deficits have completely resolved. 

Author: Fouad Chaudhry

 

 

7.  A 55 -years-old man sustains an open fracture of the radius which was treated with open reduction and internal fixation. This operation was complicated with radial nerve injury which did not improve at follow up. 

Which of the following treatments will best restore function?

A)Transfer of pronator teres to extensor carpi radialis brevis
B)Transfer of deltoid to triceps
C)Transfer of the flexor carpi radialis to extensor digitorum and the palmaris longus to the extensor pollicis longus 
D)Transfer of pectoralis major to biceps
E)Transfer of common flexors tendon to the humerus

Best answer: C

 

For radial nerve palsy in the forearm , the most beneficial transfers include transferring the flexor carpi radialis to the finger extensors (to restore finger extension) and palmaris longus to the extensor pollicis longus (to restore extension of the thumb).

In radial nerve palsy in the forearm, the patient has adequate wrist extension due to intact ECRL (providing radial wrist extension) supplied by the radial nerve proximal to the elbow.


Transfer of pronator teres to extensor carpi radialis brevis,and Transfer of deltoid to triceps are indicated in radial nerve palsy .

Transfer of pectoralis major to biceps and transfer of common flexors tendon to the humerus are both indicted in musculocutaneous nerve palsy. 

Ref: Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis. J Hand Surg Br. 2006 Oct; 31(5):502-6.

Author :Firas Arnaout

 

6.  A 45 years old plasterer complains of long standing pain over the lateral aspect of the elbow. The pain worsens when using a brush. 

On examination, the symptoms are exacerbated with resisted wrist extension while the elbow is fully extended. 

Which muscle is likely to be involved?

A) Anconeus
B) Brachioradialis
C) Extensor carpi radialis brevis
D)Flexor carpi radialis
E) Supinator

Best answer: C

 

This clinical presentation is consistent with lateral epicondylitis (tennis elbow), which is caused from inflammation and tendonitis at the origin of the extensor carpi radialis brevis (ECRB).

It is common with repetitive activities of supination and pronation with elbow in extension

Clinical examination findings include tenderness over the insertion of the ECRB, and pain that is reproduced with gripping, resisted long finger extension (ECRB inserts on the base of 3rd metacarpal), resisted wrist extension while the elbow is fully extended.

It is treated with activity modification, physiotherapy and steroid injections; surgery is indicated if nonoperative measures fail.

Ref: Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979 Sep;
61(6A):832-9

Author :Firas Arnaout

 

5.  Which anatomical structure provides the primary dynamic stability and restraint to the shoulder and keeps the humerus head centred on the glenoid?

A) Glenohumeral ligaments
B) Deltoid muscle
C) Rotator cuff muscles
D)Biceps muscle tendons
E) Glenoid labrum

Best answer: C

The rotator cuff is the main dynamic stabilizer of the glenohumeral joint. The rotator cuff muscles are: supraspinatus, infraspinatus, teres minor and subscapularis

The glenohumeral ligaments (superior, middle and inferior), the glenoid labrum (increases the depth of the labrum) and the shoulder joint capsule are static stabilizers.

The biceps is a secondary dynamic stabilizer.

 Ref: Netter's Concise Atlas of Orthopaedic Anatomy, Frank H. Netter, John A. Craig.

 Author :Firas Arnaout

 

4. In shoulder examination, which test is used to diagnose subacromial impingement?

A) Obrien test
B) Apprehension test
C) Cross body adduction (scarf) test
D) Speed test
E) Job test

Best answer: E

Job test is used for subacromial impingement. Performed by abduction of the shoulder to 90 degrees in the scapular plane, and internally rotate the shoulder so that the thumb is pointing down. Then press down with patient attempting to resist, the test is positive if there is pain.

Obrien test is for labral injuries, apprehension test is for instability, scarf test is for acromioclavicular joint and speed test for biceps injuries.

Ref: Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008.Page 272.

Author :Firas Arnaout

 

3.  The glenohumeral joint relies on static and dynamic stabilizers to remain centred. Which structure is the main dynamic stabilizer of the shoulder joint?

A) The glenoid labrum
B) The capsule
C) The glenohumeral ligaments
D) The negative intraarticular pressure
E) The rotator cuff muscles

Best answer: E

The glenohumeral joint is the most mobile joint in the body. All the above structures are static stabilizers, except the rotator cuff which is a dynamic stabilizer. It is innervated by C5 and C6 nerve roots .

The rotator cuff consists of the subscapularis anteriorly, supraspinatous superiorly, infraspinatus and teres minor posteriorly

 Banaszkiewicz & Kader.postgraduate orthopaedics, 2nd edition, 2012, page 151

 

Author :Firas Arnaout

 

2.  The anterior interosseous nerve innervate all of the following except:

A) The pronator quadratus
B) The abductor pollicis longus
C) The flexor pollicis longus
D) The radial half of the flexor digitorum profundus                                                                                                                                                  
E) Wriste capsule

Best answer: B

 

The abductor pollicis longus is innervated by the posterior interosseous nerve.

 

1. Dynamic muscular stabilizers of the shoulder play an important role in stability. 

Which of the following is the most important dynamic stabilizer?

A) The rotator cuff
B) The labrum
C) The coracobrachialis
D) The latissimus dorsi
E) The biceps brachii

Correct Answer: A

The rotator cuff is an important dynamic anterior stabilizer of the shoulder. The stability of the shoulder is maintained
primarily by the shoulder musculature. 

The biceps brachii has been shown to act as a dynamic stabilizer of the shoulder, but the most important dynamic stabilizer is the rotator cuff.

Author: Rajesh Bahadur Lakhey

 

5. A magnetic resonance image of a patient’s right shoulder is shown. 

The structure marked by the arrows is innervated by which of the following structures?

A) Musculocutaneous nerve
B) Branch of the posterior cord of the brachial plexus
C) Branch of the lateral cord of the brachial plexus
D) Branch of the medial cord of the brachial plexus
E) Branch of the superior trunk of the brachial plexus

Correct Answer: B

The arrows mark the subscapularis tendon. The subscapularis muscle is innervated by the upper and lower subscapular nerves. 

The upper and lower subscapular nerves are branches from the posterior cord of the brachial plexus.

 

4. This slide is a computed tomogram of the dominant shoulder of a 45-year-old male tennis player. 

The most likely diagnosis is:

A) Osteosarcoma
B) Synovial osteochondromatosis
C) Anterior glenoid fracture
D) Synovial cell sarcoma
E) Rotator cuff tear arthropathy

Correct Answer: B

Synovial osteochondromatosis is a rare condition typically affecting middle-aged men. 

The computed tomogram demonstrates the osteocartilaginous nodules. 

Early in the disease, arthroscopic removal of loose bodies and synovectomy usually results in an acceptable outcome. In cases of progressive disease resulting in secondary shoulder arthrosis, shoulder arthroplasty may be required.

 

3. This is the radiograph of a right hand dominant 15-year-old baseball player who felt a pop when swinging a bat. 

Recommended treatment should consist of:

A) Immobilization in a shoulder spica cast
B) Immobilization in a sling
C) Open reduction internal fixation with bone graft
D) Open biopsy
E) Observation

Correct Answer: E

First rib fractures in athletes are rare. These fractures are thought to be stress fractures, usually occurring in pitchers. 

Treatment is observation until the fracture is healed.

 

2. A magnetic resonance image of a patient’s right shoulder is shown. 

The structure marked by the asterisk is innervated by which of the following structures:

A) Musculocutaneous nerve
B) Branch of the posterior cord of the brachial plexus
C) Branch of the lateral cord of the brachial plexus
D) Branch of the medial cord of the brachial plexus
E) Branch of the superior trunk of the brachial plexus

Correct Answer: E

The asterisk marks the infraspinatus muscle. The infraspinatus muscle is innervated by the suprascapular nerve. The suprascapular nerve is a branch from the superior trunk of the brachial plexus.

1. A magnetic resonance image (MRI) of the dominant elbow of a 19-year-old  cricket player is presented . He has been unable to play for the past 6 weeks secondary to pain. 

The recommended treatment includes:

A) Physical therapy for triceps strengthening 
B) Physical therapy for pronator strengthening 
C) Ulnar nerve transpostion 
D) Radial collateral ligament reconstruction 
E) Ulnar collateral ligament reconstruction 

Correct Answer: E

The MRI shows a disruption of the humeral attachment of the ulnar collateral ligament. The ulnar collateral ligament of the elbow is the most frequently observed ligamentous elbow injury in cricket players. 

Recommended treatment in the throwing athlete is reconstruction of the ulnar collateral ligament with an autogenous palmaris longus graft.

Test your knowledge , learn more and get ready for your orthopaedic exam

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